Collaboration in Pennsylvania: Rapidly Spreading Improved ...acmd615.pbworks.com/f/Bricker-_IPIP_Penn.pdf · Collaboration in Pennsylvania: Rapidly Spreading Improved Chronic Care

Original Research

Collaboration in Pennsylvania: Rapidly SpreadingImproved Chronic Care for Patients to Practices

PATRICIA L. BRICKER, MBA; RICHARD J. BARON, MD, FACP; JORGE J. SCHEIRER, MD;DARREN A. DEWALT, MD, MPH; JOHN DERRICKSON; SUZANNE YUNGHANS; ROBERT A. GABBAY, MD, PHD

Introduction: Pennsylvania’s Improving Performance in Practice (IPIP) program is administered by the Pennsyl-vania (PA) chapters of the American Academy of Family Physicians, American College of Physicians, and Amer-ican Academy of Pediatrics. The project has provided coaching, monthly measurement, and patient registry supportfor 155 primary-care practices that participate in the 3-year Pennsylvania Chronic Care Initiative led by the PAGovernor’s Office of Health Care Reform.

Methods: Practices participating in this case study are attending regional Breakthrough Series collaboratives andsubmitting monthly narrative and clinical outcomes reports. The approaches to education include in-person learn-ing sessions with multidisciplinary practice teams, on-site practice coaching, conference calls, and regular feed-back of performance data. More than half will receive financial incentives from more than a dozen participatinginsurers after becoming nationally recognized Patient Centered Medical Homes by the National Committee forQuality Assurance (NCQA).

Results: In the first 6 months, practices showed improvement in diabetes process measures and a high level ofengagement in the improvement process.

Discussion: Early data reporting, practice preparation for the first learning session, monthly narrative reports frompractices, and clear and concrete change packages all seem integral to the improvement process. The future ofthe PA Chronic Care Initiative will include spreading to more practices and moving beyond the initial work indiabetes and asthma to other aspects of primary care, including prevention.

Key Words: primary care, chronic care, practice coaching, learning collaborative, system of care, quality improve-ment, Patient Centered Medical Home, education, continuing

Introduction

The problems of primary care are well documented: low payrelative to other medical specialties,1 real and projected work-force shortages as medical students turn away from primarycare,2 outdated practice models that hinder reliable deliveryof nationally recommended care,3 and payment systems that

reward fragmented acute care rather than prevention andcomprehensive chronic care management.4

With this in mind, the Pennsylvania Primary CareCoalition—consisting of the Pennsylvania Academy of Fam-ily Physicians, the Pennsylvania Chapter of the AmericanCollege of Physicians, and the Pennsylvania Chapter of theAmerican Academy of Pediatrics—jointly applied to join

Disclosures: The authors acknowledge funding and program support from the Pennsylvania Governor’s Office of Health Care Reform, participatingpayers ~Aetna, AmeriChoice, Blue Cross of Northeastern PA, Capital Blue Cross, Cigna, Gateway Health Plan, Geisinger Health Plan, Health Partners,Highmark, Independence Blue Cross, Keystone Mercy Health Plan, Unison, and UPMC Health Plan!, the Pennsylvania Department of Health, and theRobert Wood Johnson Foundation. They also acknowledge the supporting role of the National IPIP program based at the American Board of MedicalSpecialties.

Ms. Bricker: State Director, Pennsylvania Improving Performance in Practice, Vice President, Pennsylvania Academy of Family Physicians; Dr. Baron:Partner, Greenhouse Internists, Immediate Past Chairman, American Board of Internal Medicine, Co-Physician Champion, Pennsylvania Improving Per-formance in Practice; Dr. Scheirer: Medical Director, RPS Internal Medicine, Co-Physician Champion, Pennsylvania Improving Performance in Practice;Dr. DeWalt: Assistant Professor of Medicine, Division of General Internal Medicine, University of North Carolina; Mr. Derrickson: Executive Director,American College of Physicians—Pennsylvania Chapter; Ms. Yunghans: Executive Director, American Academy of Pediatrics—Pennsylvania Chapter;Dr. Gabbay: Professor of Medicine, The Pennsylvania State University College of Medicine; Director, Penn State Institute for Diabetes and Obesity.

Correspondence: Patricia L. Bricker, Pennsylvania Academy of Family Physicians, 2704 Commerce Drive, Suite A, Harrisburg, PA 17110; e-mail:[email protected].

© 2010 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Associationfor Hospital Medical Education. • Published online in Wiley InterScience ~www.interscience.wiley.com!. DOI: 10.10020chp.20067

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 30(2):114–125, 2010

the Improving Performance in Practice ~IPIP! program con-vened by the American Board of Medical Specialties andfunded by the Robert Wood Johnson Foundation. With thesupport of most of the insurers in Pennsylvania, key stategovernment agencies, and several prominent regional busi-ness groups, Pennsylvania’s IPIP application was submittedand approved in the summer of 2007.

The IPIP program was designed to bring together stake-holders within a state and to build statewide infrastructurefor primary-care improvement. The model includes healthprofessional education on improvement methods and clini-cal content, performance measurement and reporting, andenduring collaborative improvement networks for sharingdata and ideas.

At the same time, Pennsylvania Governor Edward G. Ren-dell formed the Pennsylvania Chronic Care Management, Re-imbursement and Cost Reduction Commission ~commonlycalled the Chronic Care Commission! to develop a strategicplan to address lagging chronic care quality indicators com-pared with other states and rising health care costs. Thiscommission—including representatives from health plans,physicians, hospitals, nurses, federally qualified health cen-ters, consumers, educators, academic medical centers, laborunions, and state government—presented a strategic plan toGovernor Rendell and legislative leaders in February 2008,laying out the case for improving chronic care in Pennsyl-vania and detailing the specific goals of the initiative.

The strategic plan noted that about half of Pennsylva-nians have at least 1 chronic disease and those patients withchronic disease account for 80% of all health care costs,80% of hospitalizations, 76% of physician visits, and 91%of filled prescriptions in Pennsylvania.5 Using data fromthe Pennsylvania Health Care Cost Containment Council,the plan projected more than $4 billion in unnecessary hos-pital charges for avoidable hospital admissions by chroniccare patients in 2007, up from $3.7 billion in 2006 and $3.4billion in 2005.6 National benchmarking showed Pennsyl-vania ranked in the bottom third of states for avoidablechronic disease–related hospitalizations. According to a 2005study by the Agency for Healthcare Research and Quality~AHRQ!, Pennsylvania had 4 times the rate of hospitaliza-tions for diabetes as the best-performing states and 3 timesthe rate of hospitalizations for pediatric asthma as the best-performing states.7 These statistics, coupled with the risingincidence of both diabetes and asthma in Pennsylvania,8 ledto an initial focus on adult diabetes and pediatric asthma inthe PA Chronic Care Initiative. In early 2008, PA IPIP joinedthe MacColl Institute and Bailit Health Purchasing as con-sultants to the Governor’s Office of Health Care Reform tohelp implement the PA Chronic Care Initiative.

The Chronic Care Commission established 4 strategicgoals for the PA Chronic Care Initiative.

1. Widespread use of a primary-care reimbursement model thatrewards use of the Chronic Care Model, team-based care,patient-centered care coordination, delivery of evidence-

based care, patient self-management, quality outcomes, timelyaccess to care, use of a patient registry system, and cultur-ally and linguistically competent care.

2. Broad dissemination of the Chronic Care Model through re-gional chronic care learning collaboratives.

3. Improvement in chronic care patient satisfaction, access toservices, health status, function, and quality of life; improve-ment in primary care provider satisfaction; improvement inhealth resources utilization; and improvement in clinical pro-cess and outcome measures.

4. Reduction in the cost of providing chronic care by reducingavoidable hospitalizations and ER visits, with mechanismsto assure that some of the savings are realized by all entitiespaying for health care.9

Methods

Overview

The PA Chronic Care Initiative is spreading the Chronic CareModel implementation across the state in waves of regionalcollaboratives. Practices were invited to submit applicationsto participate in the program. The professional societies sentinformation about the program to all physician members inthe regions, and the Governor’s office and payers also madeannouncements about the opportunity to participate. Of theapproximately 300 practices that applied to participate, 155were selected by the Governor’s Office of Health Care Re-form to participate and signed multiyear agreements to at-tend learning sessions, file monthly reports, and implementthe Chronic Care Model. Practices were selected to assurediversity of size, ownership, and patient mix in each collab-orative. A small number of practices were removed from con-sideration because of incomplete applications. For the initialcollaboratives, all practices are receiving a small stipend tooffset costs of attending the in-person sessions. In selectedregions, payers have created incentive programs to pay forcare consistent with the Chronic Care Model and to help sup-port the practice infrastructure needed to succeed.

Improvement Support for Practices

Teaching Improvement Methods. Primary-care practices par-ticipating in the PA Chronic Care Initiative send improve-ment teams consisting of a provider champion, day-to-dayleader, clinical coordinator, and others to BreakthroughSeries–style learning collaboratives, as developed by the In-stitute for Healthcare Improvement and organized and runby the MacColl Institute.10 The collaboratives consist of 1-or 2-day learning sessions, which are in-person workshopsthat include didactic information on improvement methodsand specific clinical content, along with time to work withina team to plan practice changes and share methods acrossteams. Between the learning sessions are action periods whenpractices work on testing and implementing changes in prac-tice. Practice teams work on developing a system of care byimplementing the Chronic Care Model.11 They test changes

IPIP Supporting PA Chronic Care Initiative

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on how they identify patients, deliver care, make decisions,support patients, and collaborate across the health systemand within their communities. Practices are taught the Modelfor Improvement12 and encouraged to use rapid-cycle, smalltests of change, which lead up to broad implementation. Prac-tices test their changes with the provider champion-led careteam and patient panel, and then spread successful changesacross their practices.

The collaborative model of education was used, recog-nizing that traditional continuing medical education ~CME!does not have a great track record in changing physicianbehavior. A univariate metaregression analysis of 36 com-parisons by Forsetlund et al found that mixed interactiveand didactic education meetings were more effective thaneither didactic or interactive meetings alone.13

Quality-Improvement Coaching. Pennsylvania IPIP has pro-vided practice coaching support to participating practices,including monthly written feedback and guidance on changesbeing tested, implemented, and spread; on-site visits to helpteams problem solve and plan additional changes; resourcefulfillment of tools, forms, models, and so on; and network-ing and sharing of best practices. The practice coachingis a supplement to what occurs in the regional learning col-laboratives. The coaching is intended to accelerate the im-plementation that occurs during the periods between thein-person learning sessions by giving customized feedbackand modeling problem solving.

Reporting and Sharing Data. Practices collect data from ei-ther their electronic medical record system or an electronicpatient registry and submit monthly population-based per-formance reports on IPIP selected process and outcome mea-sures ~TABLE 1! as well as a narrative report describing thechanges they are testing, implementing, and spreading. Im-proving Performance in Practice compiles submitted datainto monthly reports showing aggregate as well as individ-ual practice performance for each reported measure over time.Practices review these reports with their improvement coachand with other practices on conference calls and during thein-person workshops. For practices that need additional tech-nology to achieve registry functionality, PA IPIP providestraining and support for a subsidized patient registry system~RMD Networks of Centennial, CO!.

Regional Strategy

The PA Chronic Care Initiative began with the southeast~SE No. 1! region in May 2008, followed by south central~SC!, southwest ~SW!, northwest ~NW!, northeast ~NE!,north central ~NC!, and back to southeast ~SE No. 2! ~seeFIGURE 1!. All types of primary care practices ~pediat-rics, family medicine, and internal medicine! were encour-aged to participate. Enrollment was by region to minimizeparticipants’ travel time and costs to and from the in-

person meetings. Most collaboratives have 20–30 partici-pating practices.

Incentives for Practices

More than a dozen health plans are supporting practices in4 of the 7 regions ~SE No. 1, SC, SW, NE!. Although themethods and amounts of payments differ across the regions~TABLE 2!, the 104 payer-supported practices are requiredto participate in their regional learning collaborative andbecome National Committee for Quality Assurance ~NCQA!–recognized Patient Centered Medical Homes to receive theincentive. The Governor’s Office of Health Care Reformfacilitated a strategy for payments to practices based on thenumber of full-time-equivalent physicians in the practice, asa proxy for total panel size. By acting as an uninterestedintermediary, the Governor’s Office negotiated this agree-

TABLE 1. Pennsylvania Improving Performance in Practice Measures

Diabetes Measures

Most recent HbA1C � 9

Most recent HbA1C � 7

HbA1C test in past 12 mo

Most recent blood pressure � 130080

Most recent blood pressure � 140090

Most recent LDL cholesterol � 100

Most recent LDL cholesterol � 130

LDL cholesterol test in past 12 mo

Annual kidney assessment

Annual eye exam

Annual foot exam

Documented self-management goal

Aspirin use

Statin prescription

ACE0ARB prescription

Annual influenza immunization

Pneumococcal immunization

Query about tobacco use

Smoking cessation counseling

Annual eye exam referral

Asthma Measures

Annual symptom assessment

Persistent asthmatics on controller medication

Annual influenza immunization

Bundle ~all or none! of 3 measures above

Asthma action plan

Query about tobacco use0exposure

Smoking cessation counseling

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FIGURE 1. Map of Pennsylvania Chronic Care Initiative regional rollouts.

TABLE 2. Regional Financial Incentives in Pennsylvania ~PA! Chronic Care Initiative

PA Region and Start Date No. of Practices and Payers Available Incentives

SE No. 1, May 2008 32 practices, 6 payers • Year 1 infrastructure� Some lost revenue from attending Learning Sessions� Registry0EMR reporting preparation� NCQA survey0application fees

• Various-sized incentive payments based on practice size forachieving recognition levels in the NCQA’s Physician PracticeConnections–Patient Centered Medical Home ~PPC-PCMH!Physician Recognition Program14 starting as soon as NCQA scoringcomplete ~practices required to achieve at least NCQA PPC-PCMHLevel 1 by Month 12!

SC, February 2009 24 practices,a 6 payers • Year 1 infrastructure ~described above!• Care management payment starting as soon as Month 13 for

practices that are either hiring or contracting for care managementservices

• NCQA PPC-PCMH Level 1-Plusb payment at Month 18 ~practicesrequired to achieve at least Level 1-Plus by Month 18!

• NCQA PPC-PCMH Level 3 payment at Month 24 for practices thathave achieved Level 3

SW, May 2009 22 practices, 4 payers Same as SC ~above!

NE, October 2009 31 practices, 2 payers • Practice support payments for 3 yr• Care management payment starting as soon as Month 4 for

practices that are either hiring or contracting for care managementservices

• Value reimbursement every 6 mo starting at Month 13 for savingsthat exceed previous payments received, prorated, based onperformance on selected improvement criteria starting at Month 12~practices required to demonstrate improvement on selected criteriaby Month 18!

NW, September 2009 16 practices, no payers $12 000 state grant

NC, November 2009 9 practices $12 000 state grant

SE No. 2, December 2009 21 practices $12 000 state grant

aFive practices agreed to participate without the payer incentives.bLevel 1-Plus � NCQA PPC-PCMH Level 1, with additional requirement for scoring as follows on selected elements: Element 3C at75% or higher; Element 3D at 100%; Element 4B at 50% or higher.



ment without violating principles of unfair trade on the partof the payers and clinical practices. Each participating in-surer pays its pro rata share of the total available to eachpractice based on the percentage of revenue that practicereceives from that insurer. For example, if Aetna constitutes20% of the revenues in Practice X, Aetna would pay 20% ofthe payment defined by the Governor’s Office. Because par-ticipating insurers pay only on behalf of their membership,not on behalf of fee-for-service Medicare or nonparticipat-ing insurers, no practice receives the full available amount.Some practices have 80% or more patients covered by par-ticipating health plans; others have less than half. Paymentsgenerally are made to practices on a quarterly basis.

Practices are expected to use these revenues to provideenhanced care management, chronic disease management,and other services associated with being a Patient CenteredMedical Home ~eg, enhanced access to care, referral andtest tracking, e-prescribing, etc!. Some of the regional in-centive programs have been more prescriptive than othersabout how practices use these revenues. Statewide, the healthplans have committed approximately $30 million over 3 yearsto the Chronic Care Initiative. This represents less than 0.1%of their collective expenditures on physician claims.

About a third of the total practices—those in NW, NC,and SE No. 2 and including 5 in south central PA who areparticipating without payer support—have received a 1-time$12,000 grant from the Governor’s Office of Health CareReform to cover the cost of participating in the learningcollaborative ~eg, foregone revenue from not seeing patientswhile attending full-day learning sessions!. Through the IPIPprogram, physicians participating in the PA Chronic CareInitiative for 1 year also are able to earn credit toward PartIV of their maintenance of board certification. Starting in2010, continuing education credits from the American Acad-emy of Family Physicians and Pennsylvania Nurses Asso-ciation will be available for both participating physiciansand nurses.

Staffing

Six staff members in the Governor’s Office of Health CareReform, 5 faculty and consultants, 3 practice coaches, 1director of quality improvement, and the state director ofthe PA IPIP program have supported the Chronic Care Ini-tiative to date, including 7 regional learning collaborativesinvolving 155 practices in 18 months, complicated finan-cial incentive arrangements negotiated via 4 regional steer-ing committees, and a statewide grant program for 3regional collaboratives.

Results

By the end of 2009, a total of 155 practices were partici-pating across Pennsylvania. Together the practices care formore than 1 million Pennsylvanians, almost 10% of Penn-sylvania’s population. The practices include all sizes, all ge-

ographies, and all primary-care specialties ~general internalmedicine, family medicine, and pediatrics!. Some are fed-erally qualified health centers, some are residency trainingprograms, and some are nurse-managed clinics. More thanhalf had an electronic medical record at the start of theinitiative.

A formal evaluation of the PA Chronic Care Initiative isslated to begin in mid-2010 and should provide insight aboutthe levels of improvement achieved, cost savings attained,and improvements in patient or provider satisfaction. Herewe present limited quantitative results and our qualitativeobservations from creating this program.

Practice-Level Change

In Pennsylvania, we have seen remarkable progress in howprimary-care practices engage in the improvement process.We have maintained a consistently high number of practicessubmitting monthly narrative and performance reports ~80%or higher in most months!. The practices have been encour-aged to begin monthly reporting as soon as possible afterthe first learning session, with the expectation that the soonerpractices start reporting data, the sooner they could startimproving. Many practices were surprised at what theylearned when they first looked at their data. Most realizedthey had more room for improvement than they thought andbecame eager to improve their performance. In Pennsylva-nia, 90% of practices have started reporting within 3 monthsof their first learning session.

We have seen steady and persistent trends in improve-ment in performance measures, as illustrated in the data fromthe first 3 regional collaboratives ~FIGURE 2!. In all 3 ~SE,SC, SW!, the rate of improvement was greater for processmeasures, such as attention to nephropathy, prescribing stat-ins, and establishing self-management goals, than it was foroutcomes such as A1C, blood pressure, and cholesterol lev-els. Early results from the later collaboratives appear to befollowing similar improvement trajectories.

Many practices have shared that their patient care today issubstantially different from their patient care before their in-volvement in the PAChronic Care Initiative. They cite greaterteamwork, better communication in their practice, and a newpartnership with patients among their most valuable out-comes.15 One practice said the program gave them permis-sion to try new things. One shared they were able to retainpatients who were planning to leave the practice, and anothershared that 1 patient became so empowered she started a sup-port group for diabetes in her apartment complex. Others saidtheir providers now have data in hand at visits to make deci-sions about patient care. Several said that using flow sheetsand other visit planning tools has improved their efficiency.

Patients also seem to appreciate the new models of carebeing developed. They like the phone calls from their doc-tor’s office to see how they are doing in between office visitsand many more are agreeing to set self-management goals~see FIGURE 2!. Some have engaged in group education

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classes or exercise programs organized by their physician’soffice.15

Team engagement in Pennsylvania has been strong, likelydue to the alignment of the Governor’s Office of HealthCare Reform, the health plans, and the provider communitythrough the primary-care societies and PA IPIP. There is asense among the teams that they are being watched by the

nation and that their work and success may help determinethe future of primary care. The enthusiasm for this work ispalpable across the entire improvement team as they expe-rience a positive change in how they provide care.

Even so, some practices have achieved greater levels ofimprovement than others. Several practices began imple-menting electronic medical records just as they were begin-

FIGURE 2. Average practice performance for the first 6 months in each of the first 3 regional collaboratives in Pennsylvania ~SE, SC,SW!. The time periods are as follows: SE PA, June 2008 through November 2008; SC PA, March 2009 through August 2009; SW PA,June 2009 through November 2009. Early improvements were seen in process measures, such as patients with attention to nephropathy,statin prescriptions, foot exams, and self-management goals. Outcome measures for hemoglobin A1C, blood pressure, and LDL~cholesterol! improved more slowly. Note that the statin measure was added in September 2008.



ning to participate in the PA Chronic Care Initiative. Thesepractices were challenged to report on the measures as theytransitioned from paper to electronic records and generallyhad more limited time for performance improvement workduring their electronic medical records implementation. Otherpractices were challenged by staff and physician absencesand turnover. For example, 3 of the practices had lead cli-nicians become ill during the process. The effect of theseevents on ability to make progress reminds us of the fragil-ity of small practices.

Program-Level Change

Just as at the practice level, there is continuous improve-ment in the program infrastructure at the state0program level.The rapid regional spread schedule of the PA Chronic CareInitiative has provided rapid-cycle opportunities to evaluatehow participating practices are being taught and supported.As a CME program, The PA Chronic Care Initiative is fo-cused on achieving change in practice and improved out-comes for patients. In this regard, we continually assess theeducational mission of the program. We review qualitativefeedback from each learning opportunity combined with thequantitative information reflected in the practice reports.

One example of state-level improvement of the regionalcollaboratives was additional time and effort devoted to pre-work before the practices started attending learning ses-sions. After the first regional collaborative, we began givingpractices a month to 6 weeks to review an introduction tothe Chronic Care Model, form their improvement team, iden-tify their patients, collect baseline outcomes data, and pre-pare a poster presentation about their practice for the firstlearning session. Having this groundwork done prior to thefirst learning session allows much better use of the in-person time together at the collaborative and enables prac-tices to get right to work on improvement.

Cumulative monthly practice narrative reports providethe story that goes along with the data. Although time-consuming to complete, monthly narrative reports help teamstrack and record their improvement work. The practicecoaches and quality improvement director compare the nar-rative to the data to provide monthly feedback and strategicguidance to each team. The narrative report template hasbeen revised several times to make it clearer and easier tocomplete. See FIGURE 3 for an example of the current Year 1narrative report template.

The faculty have added more specific guidance on changesthat should be tested before the second learning session.This specificity, or prescriptiveness, has seemed to help prac-tices leave the first learning session with more focusedand well-developed plans for change. For example, morepractices starting in Fall 2009 immediately developed anelectronic- and0or paper-based system to identify their di-abetes patients readily so they could provide planned careany time they saw the patients. Such an identification sys-tem allows practices to identify and close any gaps in care

in patients that might otherwise be lost to follow-up. It alsohelps speed up the improvement work as gaps in care arefilled more quickly.

Discussion

The PA Chronic Care Initiative has made remarkable progresstoward transforming primary care in the state. One hundredfifty-five practices are engaged, are reporting performancedata monthly, and are actively participating in improvementcollaboratives. The organization of the initiative itself con-tinues to evolve and improve to disseminate best care forour patients more rapidly. Early performance data indicatesubstantial improvement in care processes. We anticipateadditional growth and improvement of the program and ofthe care received by the patients in PA.

Following a model of continuing education, the programis helping practices implement reliable systems for practic-ing evidence-based medicine. Although we use lecture for-mat and didactic strategies, they are coupled with ongoingdata collection and reporting along with active collaborativesharing. Additionally, the content of learning is more aboutthe systems and processes of care than it is about traditionalclinical topics in diabetes and asthma. This style of learningde-emphasizes traditional models of separate education forphysicians, nurses, and other staff and brings members ofthe care team together. This also lays the groundwork forongoing learning about systems-based care within the prac-tice and translates to improved care for the patient.

As more and more practices pass the 1-year mark in theirwork in Pennsylvania, we are discussing additional changesin care beyond diabetes and asthma so that other chronicillnesses and preventive services get subsumed into the im-proved processes. Spreading the system of care necessitatesthe practice to understand fully its processes of care. We stillbelieve that initial work in 1 disease population affords thepractice the opportunity to learn new processes and put inplace new systems, but primary-care addresses numerousacute and chronic illnesses and preventive services that canbenefit from new approaches.

Another key question at the state program level is whatlevel of practice support is needed for ongoing improve-ment beyond the first year. In the first year, coaches providemonthly feedback on team progress, and call or visit mul-tiple times. We expected that practices would need less sup-port over time, but we are finding that after 1 year, ongoingsupport seems helpful. The process of change in clinicalpractice takes time, and stable, reliable systems are often notin place within 1 year. Moreover, as new content becomesavailable, some level of practice support is needed to helpwith implementation. We hope that the role of the practicecoach can become more of a connector and facilitator ofsocial connections and spread of ideas and that expertise atthe practice level will help to sustain implementation.

Not all practices improve at the same rate, and we arediscussing the best way to allocate limited practice coaching

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~continued!

FIGURE 3. Year 1 Narrative Report Template ~3 pages!. This is a cumulative monthly report. Teams add to it every month to note thechanges they are testing, implementing, and spreading.



~continued!

FIGURE 3. Continued

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FIGURE 3. Continued



and support resources. One approach is to stratify the prac-tices based on the levels of clinical improvement they haveachieved and then to allocate the level of coaching supportbased on the level of stratification. This consideration hasled to a discussion of where to invest the most time: withthe high-performing teams to learn what they are doing for“best practices” replication, with the lower-performingteams to help them achieve greater improvement, or withthe midperforming teams that are not far from becominghigh-performing teams. These decisions create a constanttension in how to allocate limited resources and are impor-tant topics for learning across all the state IPIP programs.

We are also experimenting with another approach to prac-tice support by facilitating practice-to-practice learning via“communities of practice.” 16 We may, for example, facili-tate a community for residency programs, solo practices, orfederally qualified health centers. An initial effort to facil-itate a pediatric practice community has been very success-ful. Since the summer of 2009, the pediatric practices fromacross different regions have had monthly conferencecalls specific to asthma issues and have had an asthma list-serv separate from the regional collaborative listservs. Thepediatric practices have appreciated having time and a com-munications vehicle to discuss asthma separate from diabe-tes, which has tended to overshadow asthma in the regionalcollaboratives by virtue of so few practices working onasthma.

Exploring options for practice support is especially im-portant given the limited number of people working on thePA Chronic Care Initiative. As the program grows, withoutcommensurate growth in programmatic budget, we will needto reduce the amount of personal coaching and other sup-

port that we provide to practices. It is possible that the mo-mentum achieved, natural social networks, and efficienciesin how to teach the content will obviate some of the currentcoaching. However, we will continue to follow improve-ment trajectory closely and revisit the intensity of coachingif improvement pace slows down.

A remaining question—and the 1 asked most fre-quently—is what comes next? Given the 3-year financialinvestments by insurers in 4 of the 7 regional collaborativesin Pennsylvania, the PA Chronic Care Initiative represents anew way of thinking about how to purchase primary care.Although the optimum level of investment is not known, itseems clear that some level of investment in primary-carepractices is beneficial in achieving higher levels of commit-ment, achievement, and performance improvement. It alsoseems clear that the insurers are eager to assure that theirinvestment is well spent. Insurers in Pennsylvania have helpedpay for practice coaching in the PA Chronic Care Initiativeand may wish to continue that support to protect their in-vestment in primary-care practice transformation. The re-sults of the statewide evaluation will be central to discussionsfor expansion and spread of the PA Chronic Care Initiativeand a revised primary-care payment system that centers onpopulation management.

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Lessons for Practice

• Prework is an important part of a learningcollaborative that should not be skipped.

• Narrative reports help practice coaches pro-vide feedback and strategic guidance, asteams track and record their quality im-provement work.

• To help practices focus and plan tests ofchange, prescribe what practices shoulddo between the first and second learningsessions.

• The sooner practices begin to report data,the sooner they can begin to improve.

• Regular team meetings and consistentmonthly reporting may be predictors ofimprovement.

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10. The Breakthrough Series: IHI’s Collaborative Model for AchievingBreakthrough Improvement. IHI Innovation Series white paper. www.IHI.org. Boston: Institute for Healthcare Improvement; 2003.

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12. Institute for Healthcare Improvement. How to improve. http:00www.ihi.org0IHI0Topics0Improvement0ImprovementMethods0HowToImprove. Accessed February 6, 2010.

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